Pulmonary Flashcards
- upper airway
- lower airway
- terminal airway
- upper airway: nasal cavity - pharynx - sinuses - larynx
- lower airway: trachea - bronchi - bronchioles
- terminal airway: alveoli
arterial blood gases
- PaO2
- PaCO2
- H+ (pH)
- H2CO3 (bicarbonate)
- O2 Sat
- PaO2: 75-100mmHg
- PaCO2: 35-45mmHg
- H+ (pH): 7.35-7.45mm/mL (acidity)
- H2CO3 (bicarbonate): 20-29 mEq/L
- O2 Sat: 95-98+% / chronic resp. illness > 86%
normal excursion of the chest wall
- inspiration: active muscle contraction (diaphragm & intercostals) - intra-thoracic volume increases - changes in pressure gradients - bucket handle (lower ribs) increases transverse diameter - pump handle (upper ribs) increases AP diameter
- expiration: passive recoil of lung structures (due to elastin) - intra-thoracic volume decreases
- forced expiration: rectus abdominus - internal and external obliques, TA
abnormal excursion of the chest wall
- disease of respiratory muscles: muscular dystrophy - SCI - polio - ALS - neuropathies
- rib cage movement problems: bony (kyphosis, scoliosis, trauma, ribs or thoracic fx) - pleural problems (infection, fibrosis, adhesions) - lung tissue problems (inflammation, infection) - altered abdominal motion (ascites, pregnancy)
- altered movement into alveoli: blocked or narrowed airways, broncho-constriction, excess secretions, obstructions and/or consolidations
common diagnoses
asthma - bronchitis - emphysema - COPD - cystic fibrosis - pneumonia - restrictive lung dysfunction
*non cardiac chest pain
pulmonary interventions
- airway clearance techniques
- breathing exercises
- exercise progressions
- patient education
airway clearance: secretion management
- secretions = mucus, phlegm, sputum
- normal adults produce ~1L mucus / day
- mucus functions to trap foreign particles along with cilia that help to propel mucus/foreign particles back towards the upper airway to be expelled = mucociliary clearance
- abnormal clearance = infection, respiratory exacerbations, decreased exercise/activity tolerance
secretion characteristics
- amount
- color
- consistency
- amount: normal (none/scant) or abnormal (measurable amount mL, tsp, or cups)
- color
- red = blood
- purple = neoplasm
- yellow = infection
- green = pus
- pink = pulmonary edema - consistency: thin/watery, thick, frothy, purulent (pus)
secretion removal techniques
- postural drainage
- chest PT
- coughing/huffing
- active cycle of breathing and autogenic drainage
- breathing techniques
- positioning
postural drainage
uses gravity and positioning to drain secretions from various lung lobes into larger airways to be expelled
- lung segments are positioned 90degrees from horizontal
- secretions are moved from peripheral to central airways
- minimum of 10 minutes per position
contraindications to postural drainage (6)
- unstable head or neck injury
- recent spinal injury or surgery
- cranial hemorrage with ICP > 20 mmHg
- large pleural effusion
- pulmonary edema due to CHF
- PE
chest PT
use of mechanical energy through the chest wall to loosen airway secretions
- manual: percussion, vibration, clapping, shaking, cupping
- mechanical: high velocity chest wall oscillator, chest vibrators
- can use in conjunction with postural drainage positions
contraindications for CPT (6)
- acute asthma attack or severe bronchospasm
- burns, open wounds, recent skin grafts, infection
- flail chest
- lung contusion
- osteoporosis/osteopenia
- osteogenesis imperfecta or other brittle bone disease
flail chest
occurs when a segment of the thoracic cage is separated from the rest of the chest wall
- defined as at least two fractures per rib (producing a free segment) in at least two ribs
- a segment of the chest wall that is flail is unable to contribute to lung expansion
positive airway pressure
splints the airways open during inspiration and/or expiration to prevent alveolar collapse
- positive expiratory pressure (PEP)
- positive end expiratory pressure (PEEP): 15min treatments performed in sitting
- intermittent positive pressure breathing (IPPB): 15-30min treatments sitting or lying
- continuous positive airway pressure (CPAP): short or longer durations, usually worn at night
cough characteristics
- dry: non-productive
- moist: productive or non-productive
- paroxysmal: sudden fit of severe coughing
- weak: usually without glottis closed and limited increase in intra-thoracic pressure
huff
- inhale deeply through the mouth
2. forcefully and rapidly exhale while contracting abdominal muscles and say “ha ha ha” (glottis remains open)
cough
- inhale maximally, close glottis and hold 1-2 sec
- high velocity maneuver with closed glottis after deep inspiration
- forces secretions out of large/upper airways
- repeat 2-3x
active cycle of breathing (ACB)
used for breathing control, thoracic expansion, and forced expiration
- normal relaxed breathing at pt’s own tidal volume x 5-10sec or 2-3 cycles
- SLOW deep breathing to maximal volume, with passive exhalation x 3-4 cycles
- 1-2 huffs at mid-low tidal volume
- brisk adduction of upper arms to torso to self compress the chest/thorax with exhalation
- normal tidal breathing can be added as needed between steps
autogenic drainage
cyclic breathing that “milks” secretions from smaller to larger airways
- ACBT performed with huffs at low lung volumes
- ACBT performed with huffs at mid lung volumes
- ACBT performed with huffs at high lung volumes
apnea
absence of breathing
tachypnea
fast RR, decreased depth (shallow)
bradypenea
slow RR, increased or normal depth
orthopnea
difficulty breathing in positions other than upright/erect
cheyne-stokes
alternating bouts of increased RR and apnea
dyspnea
shortness of breath
breathing techniques
- diaphragmatic breathing
- inspiratory muscle re-training (IMT)
- paced breathing and exhale with effort
- pursed ip breathing (PLB)
- segmental breathing
- incentive breathing
paced breathing with activity
- inhale before or during “easier” parts of an activity
- exhale upon exertion/effort
- breaks activity up into slower tempo/manageable intervals
- avoid valsalva or holding breath
pursed lip breathing (PLB)
- breathe in slowly through nose for 2 counts
- pucker your lips as if you were going to whistle
- gently and slowly exhale as if you were trying to make a candle flicker for 4 counts
- creates a relaxing effect
- assists with emptying of lungs
segmental breathing
- localized breathing or thoracic expansion
- position patient as indicated: PD positions may be used
- therapist places hand on area to be expanded: have pt breath into hand (minimal to no force applied)
- on exhalation: therapist applied firm pressure to area at the end of exhalation
- can add a quick stretch at end of exhalation if indicated
incentive spirometry (sustained maximal inhalation)
- sit or lie upright in a comfortable position
- hold incentive spirometer upright with both hands
- slide indicator to desired level and slowly raise it as pt improves
- with lips tightly sealed around mouthpiece, breath in slowly and deeply
- hold breath for at least 3 sec and let piston fall back down
exercises for chest wall expansion
- pectoralis and cervical stretches
- shoulder ROM activities
- postural muscle strengthening and re-education
- PNF (D2)
- foam roller
aerobic exercise prescription
- mode: rhythmical activities using large muscle groups, better with total body activity, performed continuously
- intensity: THR 55-90% depending on variety of factors
- duration: 20-60min or 10min bouts cumulatively
- frequency: 3-5x/wk
pulmonary symptom aggravatros
- anything that increases work of breathing
- pain
- edema (pulmonary)
- anxiety/stress/fear
pulmonary symptom alleviaters
- secretion removal, breathing techniques and positioning
- reassurance and relaxation
- offer oxygen and/or bronchodilator if prescribed by MD
- splinting or supportive overpressure
- pacing, activity modification
- education
oxygen
- MD prescription
- dosage in L (2L O2 via nasal cannula)
- titration: ability to change to dose (titrate to 90% O2 sat)
tools to assess efficacy of treatment
- ausculation
- pulse ox
- sputum production
- dyspnea rating (borg, RPE)
- functional and exercise tolerance tests
- observations
- compare pre and post treatment
